<table border=0 cellpadding=2 width=100%>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>  $LDExtraInfo<br>($LDInsurance) </td>
     <td><textarea name='aux_notes' cols=60 rows=2 wrap='physical'></textarea></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color=red>*  $LDGotMedAdvice </td>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 		<input type='radio' name='short_notes' value='got_medical_advice'>   $LDYes 
         	<input type='radio' name='short_notes' value=''>   $LDNo 
         </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='red'>*  $LDDiagnosis </td>
     <td><textarea name='text_diagnosis' cols=60 rows=8 wrap='physical'></textarea></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='red'>*  $LDTherapy </td>
     <td><textarea name='text_therapy' cols=60 rows=8 wrap='physical'></textarea></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='red'>*  $LDDate </td>
     <td><input type='text' name='date' size=10 maxlength=10 $TP_date_validate >
	 <a href="$TP_href_date"><img   $TP_img_calendar ></a> 
	<font size=1>[ $TP_date_format ]</font>
	 </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='red'>*  $LDBy </td>
     <td><input type='text' name='personell_name' size=50 maxlength=60 value='$TP_user_name' readonly></td>
   </tr>
</table>
